Is bone grafting justified in a patient with a lateral tibial plateau fracture with vertical fracture lines and mild cortical depression undergoing open reduction and internal fixation (ORIF) of the tibia?

Bone Grafting in Lateral Tibial Plateau Fractures with Vertical Fracture Lines and Mild Cortical Depression

Bone grafting is not routinely justified for lateral tibial plateau fractures with mild cortical depression and vertical fracture lines undergoing open reduction and internal fixation (ORIF), as modern periarticular rafting constructs can achieve good results without the additional morbidity associated with bone grafting. 1

Indications for Bone Grafting in Tibial Plateau Fractures

Bone grafting should be considered only in specific circumstances:

• Severe depression (>11mm)
• Significant metaphyseal comminution
• Poor bone quality/osteoporosis
• Posterolateral depression that is difficult to support with standard fixation 1

Decision Algorithm for Bone Grafting

1. Assess fracture characteristics:

   • Measure articular depression (if <11mm, bone grafting likely unnecessary)
   • Evaluate for metaphyseal comminution (mild comminution doesn't require grafting)
   • Assess bone quality (normal bone density doesn't require grafting)
   • Determine fracture location (anterolateral fractures are more stable than posterolateral)

2. Consider fixation technique:

   • Modern periarticular rafting constructs with subchondral screws provide excellent support
   • Lateral locking plates with multiple subchondral screws can adequately support mild depression

3. Evaluate patient factors:

   • Age and bone quality
   • Activity level and weight-bearing demands
   • Comorbidities that might affect healing

Surgical Management Approach

For lateral tibial plateau fractures with vertical fracture lines and mild cortical depression:

• Anterolateral approach with submeniscal arthrotomy for direct visualization 2
• Elevation of depressed fragments under direct visualization
• Subchondral support with 2.7mm locking screws placed strategically 2
• Lateral locking plate application for definitive fixation

Potential Complications to Consider

Bone grafting adds potential complications:

• Donor site morbidity (with autograft)
• Increased infection risk
• Prolonged operative time
• Delayed rehabilitation

Evidence-Based Outcomes

Studies show that stable fixation with periarticular locking plates and subchondral screws without bone grafting can achieve excellent results in lateral tibial plateau fractures with mild depression:

• 31.7% excellent and 51.21% good outcomes reported with ORIF of lateral tibial plateau fractures 3
• Modern fixation techniques with subchondral screws provide adequate support for mild depression 2

Important Considerations

• Ensure adequate visualization of the articular surface during reduction
• Consider arthroscopically assisted techniques for better visualization in complex cases 4
• Focus on anatomic reduction of the articular surface and stable fixation
• Early mobilization improves outcomes, so fixation should be stable enough to allow this 1

In summary, while bone grafting has traditionally been used for tibial plateau fractures, current evidence suggests that modern fixation techniques can adequately manage lateral tibial plateau fractures with mild cortical depression without the need for bone grafting. Reserve bone grafting for cases with severe depression (>11mm), significant metaphyseal comminution, poor bone quality, or posterolateral depression that is difficult to support with standard fixation.